Defining and Developing Good Evidence for Policy and Practice

Transcription

1 Defining and Developing Good Evidence for Policy and Practice Ruth E Mann, PhD National Offender Management Service, England & Wales

2 Overview Reflections on the treatment effectiveness literature from an evidence based policy perspective Targets for change for therapeutic work with sex offenders Evidence-based methods & new ideas

3 From sex offender treatment to evidence based commissioning: A change in perspective From sex offender treatment lead to commissioning strategy An organisation committed to evidence-based policy Setting standards for evidence based policy Assessing the evidence base to inform commissioning strategy Colleagues and Collaborators

4 Working in an evidence-led agency NOMS is committed to evidencebased commissioning. Wherever possible, we will use sound evidence to inform the commissioning decisions we will take to obtain our outcomes. Evidence will count more strongly than intuition or habit as we prioritise services and subgroups or segments of offenders.

5 Two aspects of evidence-based policy as opposed to policy-based evidence Develop policies based on evidence Identify and read the appropriate evidence, identify the evidence based principles and conditions, develop the policy, acknowledge limitations Evaluate policies during implementation Using a high quality research design

6 Threats to Evidence Based Policy-Making Vested Interests Lack of data Ideological blinders Attraction of anecdotes Vs. the evil twin : Policy-based Evidence-Making

7 What is the evidence for sex offender treatment effectiveness?

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9 RCTs only, any outcome 10 studies, of which 5 had some sort of reconviction outcome, and 2 were large scale robust reconviction studies CBT, Behavioural and Psychodynamic 3 studies had outcome variables not now judged criminogenic

10 RCTs and prospective observational studies, broad reoffending outcome. Sexual abusers of children only (adults, adolescents, children with sexual behaviour problems). 8 studies included; 5 with adult perpetrators.

11 Meta-analysis of outcome studies with equivalent treatment and control groups (Maryland 3-5). Outcome criterion was official measures of sexual recidivism. 28 comparisons identified.

12 Meta-analysis of outcome studies rated as good or weak (accepted weaker studies than Langstrom et al. or Dennis et al.). Only 5 rated as good design. 22 studies, recidivism outcome (incl self report). Rated according to compliance with RNR criteria.

13 What do the systematic reviewers conclude about the quantity and quality of the evidence? The main finding of this systematic review is that there was no evidence from any of the trials in favour of the active intervention in a reduction of sexual recidivism. (Dennis et al., 2012) The scientific evidence was insufficient to determine if cognitive behavioural therapy with relapse prevention reduces reoffending. No scientific evidence was available to determine if [other] psychological interventions reduce sexual reoffending. (Langstrom et al., 2013)

14 What do the systematic reviewers conclude about the quantity and quality of the evidence? The sexual and general recidivism rates for treated sex offenders were lower than the rates observed for comparison groups [but] Reviewers restricting themselves to the better quality, published, studies could reasonably conclude that there is no evidence that treatment reduces sexual offence recidivism (Hanson et al., 2009) The analyses suggest that treatment of sexual offenders can be effective. Sexual offender treatment is a promising part of an evidence-oriented crime policy. (Schmucker & Losel, 2013).

15 More research is always needed [There were] far fewer than the number [of studies] that would give one any confidence in the findings Our inescapable conclusion is the need for further RCTs. (Dennis et al., 2012) Better coordinated and funded high quality studies including several countries are needed. (Langstrom et al., 2013)

16 In this case, it seems to be essential. Strong studies are needed. Of the 128 studies examined, none were rated as strong. Skeptics will only be compelled to change their opinions by the strongest possible evidence. (Hanson et al., 2009). More randomized trials and high-quality quasiexperiments are needed, particularly outside of North America. In addition, there is a clear need of more differentiated process and outcome evaluations that address the question of what works for whom under what circumstances and with regard to what outcomes. (Schmucker & Losel, 2013)

17 So, what s the evidence-based position? Are we OK just to carry on? If the programme is of unknown efficacy, is it legitimate to detain individuals [for treatment]?... In practice, it is likely that both pharmacological and psychological therapies will need to be used in unison in order to obtain the greatest benefit (Dennis et al., 2012) The most ethically defensible position would be to assess the presence of treatable risk factors and offer individualised treatment. Ensure that the model complies with the risk, need and responsivity principles. (Langstrom et al., 2013)

18 It seems not. We may need to think differently. Attention to the need principle would motivate the largest changes in the interventions given to sexual offenders Consequently it would be beneficial for treatment providers to carefully review their programmes to ensure that the treatment targets emphasised are those empirically linked to sexual recidivism. (Hanson et al., 2009). CBT may not be the most important feature of an effective approach; inclusion of individual sessions may produce better results (but confounded); flexible manuals; focus on high risk offenders. (Schmucker & Losel, 2013)

19 Getting the Treatment Targets right

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21 We have a good understanding of what factors best predict reconviction Sexual interests Attitudes and beliefs Relationships Self regulation Sexual preoccupation, deviant sexual interests Offence supportive attitudes; hostile schemas Lack of intimacy with adults, emotional congruence with children Impulsivity, poor problem solving, non-compliance with rules

22 We are starting to think about what protects people from reoffending Healthy sexual interests Capacity for emotional intimacy Constructive social and professional support network Goal directed living Good problem solving Engaged in employment or constructive leisure activity Sobriety Hopeful, optimistic and motivated attitude to desistance

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24 And we know there are some things that seem not to be related to reoffending Victim empathy Taking responsibility for offending

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26 Evidence-based methods for addressing criminogenic attitudes and beliefs

27 Beliefs about sexual offending have been found to be related to recidivism Offence-supportive attitudes, including child molester attitudes (e.g., children are not harmed by sex with adults), pro-rape attitudes (e.g., rape victims enjoy or deserve rape), sexual entitlement (e.g., sexual needs must be met), general assessments of the immediate, emotional evaluation (valence) of sexual offending (e.g., sexual offending is fun). These beliefs may surface in relation to particular offences in the form of minimisation of harm (the belief that the victim was unharmed by or even enjoyed the abusive behaviour) and victim blaming (the belief that the victim encouraged or was responsible for the abusive behaviour).

28 And some beliefs about the self and the world (schemas) are also indicated, although the evidence is less extensive A view of oneself as disadvantaged by events of life A view of oneself as dangerous, deviant, and/or disgusting (because of one s sexual desires or sexual behaviours) A hostile attributional bias, where the behaviour of others is habitually interpreted as hostile and malign A belief that children are sexual beings who are capable of sexually mature desires and behaviour, including sexual provocation, and who are not harmed by sexual relations with adults A belief that the world is dangerous and that people must attack, dominate and get revenge in order to survive it A need for respect from others, which if not forthcoming must be obtained through dominance

29 Methods for addressing criminogenic cognitive content & process Cognitive restructuring Schema therapy Empathy training

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31 What does cognitive restructuring involve? Collaboratively, therapist and client identify problematic cognitions and agree that they are problematic. The therapist applies Socratic questioning to assist the client to evaluate the problematic cognition in terms of its rationality and evidence base. The client is encouraged to identify rational rebuttals to the original problematic cognition, The client is invited to consider and weigh up the evidence for both the original belief and the newly articulated rebuttal.

32 Cognitive restructuring: Evidence review suggests it s effective According to a survey of treatment providers in the USA, cognitive restructuring is the most common procedure adopted to change sexual offenders cognitions (McGrath et al., 2010), although this survey relied on self-report and so could not verify that the techniques used in these programmes actually met the definition of cognitive restructuring. Beech et al (2013) identified three studies that evaluated the impact of cognitive restructuring on sex offenders cognitions (Bumby, 1996; Bickley & Beech, 2003; and Williams, Wakeling & Webster, 2007) and concluded that this technique is effective in relation to beliefs about children and sex.

33 But cognitive restructuring may be incorrectly understood in our typical treatment approach Cognitive restructuring is not a process designed to change an offenders account of his offence and is not a method to push someone to take responsibility for his offending (i.e., present his offence account without minimisation, justification or denial). While the majority of US programmes have reported that cognitive restructuring is one of their main treatment methods, they have simultaneously reported that taking responsibility for the offence is one of their main goals.

34 What does schema therapy involve? Explain the concept of schemas to the client. Teach the client to identify and articulate their individual schemas through a process of recognising patterns in their thinking across their lives. Teach the client self-challenge techniques, especially the need to consciously create alternative explanations and then gather evidence both for the original schema-driven interpretation as well as for alternative interpretations. The client practices in the therapy setting.

35 Schema therapy: Evidence review suggests it s useful Limited research, none examining reoffending outcomes Schema therapy seems to reduce grievance thinking (Barnett, 2011) and entitlement and suspiciousness schemas (Thornton & Shingler, 2001). A different programme developed just for rapists (Eccleston & Owen, 2007) fared less well: the schemas held by group members were intractable and highly resistant to change. A randomised controlled trial (RCT) of Schema Modal Therapy for personality disordered patients in a high security hospital (Tarrier, Dolan, Doyle, Dunn, Shaw & Blackburn, 2010) reported no statistically significant impact on a range of schema measures

36 Should we move our focus from victim empathy to empathy training? Empathy deficits in sexual offenders could more usefully be viewed as cognitive deficits. That is, they arise from weaknesses across a range of cognitive processes, including weaknesses in perspective taking. Empathy-enhancing sessions often utilise methods that are highly experiential, often involving psychodramatic activities (e.g., Mann, Daniels, & Marshall, 2002; Webster, Bowers, Mann, & Marshall, 2005).

37 Empathy training: Evidence review suggests it changes attitudes Analyses of the effects of these sessions on cognition have established that they appear to bring about reductions in offence-supportive beliefs such as attitudes that children enjoy and provoke sexual contact with adults (e.g. Pithers, 1994; Beech, Fisher & Beckett, 1998).

38 A move from victim to general focus retains our strong methods but enables more generalisation Such experiential methods are effective approaches for challenging relevant attitudes, but, to avoid inducing shame or undermining the development of a nonoffending identity that can aid desistance from offending, as well as to avoid conflation of treatment with punishment, they should be focused on enhancing the general cognitive skill of perspective taking, rather than narrowly focused on enhancing empathy for the particular victim of a participant s offence.

39 Methods for improving self regulation Cognitive skills training Mindfulness training

40 What is cognitive skills training? The example of ETS ETS: 20 two-hour sessions delivered to groups of participants by two trained facilitators. ETS: designed to boost as problem-solving, perspective taking, empathy, impulse control, and critical reasoning. A variety of cognitivebehavioral techniques are used including practical tasks, discussions, role-play, and games. Facilitators are trained to make the training materials relevant to the everyday lives of the participants and to make the sessions as interactive and as little like school as possible. More complex skills are introduced only after the basic constituent skills have been introduced. Over-learning and repetition enables the assimilation of these new skills.

41 Criminal Justice and Behavior, September 2014

42 We found differential responses to ETS according to nature of index offence 2-year reconviction rate (%) Sexual Violence Robbery Acquisitive Drugs Other Total A Predicted B Actual Main current offence ETS in custody , for adult males. N = 21,373

43 Reoffending after ETS sexual offenders with adult victims Predicted 30 Actual < Sex offenders in custody, , N = 589

44 Reoffending after ETS sex offenders with child victims Predicted Actual 10 0 < Sex offenders in custody, , N = 1235

45 No sexual offence specific information Small n, especially at higher risk levels Unusual for sex offenders to complete ETS only Denial may be the protective factor? Not a prospective, matched, study; no comparison group. Real world delivery Consistent with Robinson, CAVEATS STRENGTHS

46 If ETS did reduce sexual reoffending, what can we learn from this? No need for an offence focus? Teaching skills is the most important thing? Better for an intervention to avoid implying a sex offender identity? Let s look at some other approaches that fit these principles

47 Mindfulness training

48 The case for mindfulness training is mainly theoretical Negative emotional states can lead to disturbances in individuals ability to control sexual behaviours. Teaching mindfulness techniques to those convicted of sexual offences can change prefrontal activity and improve heart rate variability, reducing anxiety and worry and improving emotional control. Training in mindful breathing meets the criteria for responsive treatment it is a physical rather than cognitive activity, it does not require introspection, and it produces immediate benefits in terms of a subjective sense of well-being.

49 But review of the early evidence suggests there s an impact on criminogenic factors Tested variants with psychiatric and forensic samples meditation on the soles of the feet controlled breathing with biofeedback mindful observation of thoughts Early studies suggest impact includes Enhanced frontal/amygdala functioning Decreased anger & hostility Increased emotional regulation Decreased anxiety and worry Improved affect labelling

50 The wise intervention literature offers important evidence-based principles about intervention design

51 What are wise interventions? Wise interventions draw on a long tradition of research (e.g., Dimidjian et al., 2006; Lewin, 1952; McCord, 1978). But they are novel in that they are psychologically precise, often brief, and often aim to alter self-reinforcing processes that unfold over time and, thus, to improve people s outcomes in diverse circumstances and long into the future. By changing the self over time, many wise interventions go beyond simple nudges changes to a specific situation or decision framework to encourage better behavior in that context (Thaler & Sunstein, 2008). Wise interventions are special remedies for social problems and afford important implications for theory.

52 Do Good Be Good a wise intervention principle that fits with the desistance literature on identity

53 Five Minutes Daily a wise intervention that improves goal setting

54 Conclusion 1 The evidence for our current approach to treating sex offenders is not strong in quality or quantity. The evidence that we do have is not convincing enough.

55 Conclusion 2 A constant theme from the systematic reviews is that we need to get our treatment content more firmly fixed on what we know to be criminogenic needs for sexual offenders.

56 Conclusion 3 Evidence-based means precise targeting, strong theory of change, wise methods, appropriate dose, and a demonstrated impact.

57 Thank